The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
b. ask the health care provider to order an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.
ANS: D
The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient's safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient's agitation and disorientation.
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